cpr feedback: the good, the bad and the ugly...cpr feedback: the good, the bad and the ugly mike...
TRANSCRIPT
![Page 1: CPR Feedback: The Good, The Bad and The Ugly...CPR Feedback: The Good, The Bad and The Ugly Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire](https://reader034.vdocument.in/reader034/viewer/2022042919/5f63c8a40ed3fe3c2809a85c/html5/thumbnails/1.jpg)
CPR Feedback: The Good,The Bad and The Ugly
Mike McEvoy, PhD, NRP, RN, CCRNEMS Coordinator – Saratoga County, NYEMS Editor – Fire Engineering magazine
Professor Emeritus – Albany Medical Collegewww.mikemcevoy.com
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Disclosures
• I don’t know how to play golf or ski
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www.mikemcevoy.com
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Outline• CPR 2010: that was then, this is now…• Show me the money: is there proof?• What matters?• Why measure?• How to assess
quality CPR• Unique hospital
issues• Future solutions
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Adult Chain of Survival: 20101. Immediate recognition and activation of
emergency response system2. Early CPR with emphasis on
chest compressions3. Rapid defibrillation4. Effective ALS5. Integrated post-cardiac arrest care
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CPR SequenceChange A-B-C to C-A-B Initiate chest compressions
before ventilations
Why? Reduce delay to
compressions Can be started immediately Emphasizes importance of
chest compressions
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So, What Matters in CPR?And how should we assess effectiveness?
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Chest Compressions2010
• > 50 mm ( > 2”)• At least 100 per
minute
2005• 38 – 51 mm (1.5 – 2”) • 100 per minute
Most Common Errors:1. Too slow2. Not deep enough3. Prolonged interruptions4. Leaning
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Chest Compressions• ROC: survival associated with depth• Abella et al: 100-120/min = survival• Recommendations are LOE 4 & 5
(just do it, because we like it)• In truth:
– Ideal actual depth of CPR unknown• Probably lies near 50 mm
– Best rate for CPR unknown• Is likely about 100/min
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CPR Rate vs. ROSC
0% 20% 40% 60% 80%
40-72
72-87
87-95
96-139
ROSCNo ROSC
p < 0.0083
Abella et al. Circulation. 2005;111:428-434
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Probability of ROSC
Stiell et al. Crit Care Med 2012; 40:1192-1198
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One Day Survival
Stiell et al. Crit Care Med 2012; 40:1192-1198
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Survival to Discharge
Stiell et al. Crit Care Med 2012; 40:1192-1198
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Effective CPR?• How do you measure the effectiveness
of CPR?– End tidal carbon dioxide– Feedback devices
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Waveform CapnographyAttaches to ET tube, measures CO2
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Oxygen Lungs alveoli blood
Muscles + Organs
Oxygen
CellsOxygen
Oxygen+
Glucose
ENERGY
CO2
Blood
Lungs
CO2
Breath
CO2
Physiology of Metabolism
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Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
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Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
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Measuring Exhaled CO2
Colorimetric
Capnometry
Capnography
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Carbon Dioxide (CO2) Production
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What If…
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But, with High-Quality CPR…
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Meet Howard Snitzer• 54-years old, collapsed Jan 5,
2011 outside Don’s Foods in Goodhue, MN (pop. 900)
• 2 dozen rescuers took turns providing CPR for 96 minutes
• 6 shocks with first responder AED, 6 more shocks by Mayo Clinic Air Flight Medics
• Transported to Mayo Clinic Cardiac Cath Lab
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Why Not Quit?• Thrombectomy, stent to LAD• 10 days inpatient • “The capnography told us not to
give up”• EtCO2 averaged 35 (range 32 – 37)
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So What’s the Goal During CPR?
• Try to maintain a minimum EtCO2 of 10 mmHg (1.4 kPa)
• PushHARD (> 2” or 5 cm)FAST (at least 100)
• Change rescuerEvery 2 minutes
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Guidelines 2010• Continuous quantitative waveform
capnography recommended for intubated patients throughout peri-arrest period. In adults:1. Confirm ETT placement2. Monitor CPR quality3. Detect ROSC with EtCO2 values
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Guidelines 2005EtCO2 recommended to confirm ET
tube placement
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Wayne MA, Levine RL, Miller CC. “Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest” . Annals of Emergency Medicine. 1995; 25(6):762-767. Levine RL., Wayne MA., Miller CC. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” New England Journal of Medicine. 1997;337(5):301-306.
EtCO2 detects ROSC• 90 pre-hospital intubated arrest patients• 16 survivors• 13 survivors: rapid rise in exhaled CO2
was the earliest indicator of ROSC• Before pulse or blood pressure were
palpable
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Capnography = Results, not process
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CPR is Complicated!
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Hospital Issues:1. Bed Height
– Optimal = bed at knee level of person administering chest compressions
Cho et al, Emerg Med J. 2009;26:807-810
2. Air Mattresses– No need to deflate mattress for CPR
Perkins et al, Inten Care Med. 2003;29:2330-2335
3. Backboards– No evidence of benefit with backboard
Perkins et al, Inten Care Med. 2003;29:2330-2335
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What About Quality?
In-Hospital Arrests, Dec 2004 – Dec 2005
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Audiovisual CPR Feedback
• Incorporated into monitor/defibrillator• Real time• Accelerometer-based
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Handheld Feedback Device
Handheld accelerometer-based audiovisual device
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Generation of Feedback
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Post Code Reviews
(Code Stat ™)
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EMS Feedback = ROSC• FDNY uses audio-visual feedback• Deactivated audio feedback for 1 week• ROSC 20%
NY State EMS Council Report Jan 2012
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But Hospitals ≠ EMS
• How effective are feedback systems?
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We have a problem:
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Accelerometer CPR Depth
Perkins et al. Resuscitation 2009;80:79-82
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The Mattress Issue:• Mattress compression = 35 – 40% of
total compression depth• Accelerometer feedback devices fail to
account for mattress compression• Use of a backboard fails to compensate
for mattress compression
Perkins et al. Resuscitation 2009;80:79-82
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CPR on Mattress
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CPR with a Backboard
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The Solution:
Directly measurethe true
compression depth.
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• Two end points• Direct measurement of distance (magnetic)• Discrimination of X, Y, Z
Triaxial Field Induction
12
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TFI versus ACC
Banville et al. Circulation 2011; 124:A217
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Summary• Compressions are key to outcomes
– Most common errors: depth and speed• Need to assess effectiveness of CPR
– It improves survival– Future hospital requirement
• Current tools: EtCO2 and ACC– CO2 delayed– ACC inaccurate
• Future: TFI – Very promising